Prevalence and Non-Invasive Predictors of Left Main or Three-Vessel Coronary Disease: Evidence From a Collaborative International Meta-Analysis Including 22 740 Patients

Study Questions:

What are the prevalence and predictors of left main disease (LMD) and three-vessel disease (3VD) in patients with acute coronary syndrome (ACS) and also in patients with stable coronary disease?

Methods:

Medline/PubMed were systematically searched for eligible studies published up to 2010, reporting multivariate predictors of LMD or 3VD. Study features, patient characteristics, and prevalence and predictors of LMD and 3VD were abstracted and pooled with random-effect methods (95% confidence intervals [CIs]).

Results:

Seventeen studies (22,740 patients) were included, 11 focusing on ACS (17,896 patients) and six on stable coronary disease (4,844 patients). In the ACS subgroup, LMD or 3VD occurred in 20% (95% CI, 7.2-33.4%), LMD in 12% (95% CI, 10.5-13.5%), and 3VD in 25% (95% CI, 23.1-27.0%). Heart failure at admission and extent of ST-segment elevation in lead aVR on 12-lead electrocardiogram (ECG) were the most powerful predictors of LMD or 3VD. In the stable disease subgroup, LMD or 3VD was found in 36% (95% CI, 18.5-48.8%), with the most powerful predictors being transient ischemic dilation during the imaging stress test, extent of ST-segment elevation in aVR and V1 during the stress test, and hyperlipidemia.

Conclusions:

The authors concluded that severe coronary disease, which is LMD or 3VD, is more common in patients with ACS or stable coronary disease than generally perceived.

Perspective:

This study suggests that LMD and 3VD are common clinical conditions, more common than generally expected, in both stable and unstable coronary disease. Furthermore, simple inexpensive and readily available clinical and laboratory tests may be helpful for screening patients with these high-risk conditions to enable them to receive optimal treatment. The most powerful predictors of 3VD and LMD appear to be ST elevation in lead aVR and a clinical finding of heart failure. These findings emphasize the importance of a good clinical examination and the ‘plain old 12-lead ECG’ for risk stratification of patients.

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Prevalence and Non-Invasive Predictors of Left Main or Three-Vessel Coronary Disease: Evidence From a Collaborative International Meta-Analysis Including 22 740 Patients